DD Form 2807-1, Report of Medical History, 20160516 draft

1 WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a$10,000 fine or both), to anyone making a false statement. Report OF Medical HISTORY(This information is for official and medically confidential use only and will not be released to unauthorized persons.)X ALL APPLICABLE BOXES:OMB No. 0704-0413 OMB approval expiresSeptember, 30 20211. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY TODAY'S DATE (YYYYMMDD) HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code) b.

2 HOME TELEPHONE (Include Area Code) 5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)ArmyNavyMarine CorpsAir ForceRegular ReserveNational Guardc. PURPOSE OF EXAMINATIONR etentionSeparationMedical BoardRetirementOther (Specify) POSITION (Title, Grade, Component)b. USUAL OCCUPATION8. CURRENT MEDICATIONS (Prescription and Over-the-counter)9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NOc. Coughed up bloodd. Asthma or any breathing problems related to exercise, weather,pollens, Shortness of breathf.

3 BronchitisYES Severe tooth or gum troubleb. Thyroid trouble or goiterc. Eye disorder or troubled. Ear, nose, or throat troublee. Loss of vision in either eyef. Worn contact lenses or glassesg. A hearing loss or wear a hearing aidc. Recurrent back pain or any back problemd. Numbness or tinglinge. Loss of finger or toeb. Recent unexplained gain or loss of weightc. Currently in good health (If no, explain in Item 29 on Page 2.)d. Tumor, growth, cyst, or need to use corrective devices such as prosthetic devices, knee brace(s), back support(s), lifts or orthotics, Bone, joint, or other deformitym.

4 Plate(s), screw(s), rod(s) or pin(s) in any bonen. Broken bone(s) (cracked or fractured)DD FORM 2807-1 OCT 2018 DoD exception to SF 93 approved by ICMR, August 3, EDITION IS Frequent indigestion or heartburnb. Stomach, liver, intestinal trouble, or Adverse reaction to serum, food, insect stings or medicinel. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)j. Any knee or foot surgery including arthroscopy or the use of a scopeto any bone or Painful shoulder, elbow or wrist ( pain, dislocation, etc.)

5 B. Arthritis, rheumatism, or bursitish. Surgery to correct vision (RK, PRK, LASIK, etc.)j. Sinusitisk. Hay feverl. Chronic or frequent coldsg. Wheezing or problems with wheezingi. A chronic cough or cough at nighth. Been prescribed or used an Tuberculosisb. Lived with someone who had tuberculosisc. Gall bladder trouble or gallstonesd. Jaundice or hepatitis (liver disease)e. Rupture/herniag. Skin diseases ( acne, eczema, psoriasis, etc.)h. Frequent or painful urinationi. High or low blood sugarj. Kidney stone or blood in urinek. Sugar or protein in urinef.

6 Rectal disease, hemorrhoids or blood from the SERVICE12.(Continued)f. Foot trouble ( , pain, corns, bunions, etc.)g. Impaired use of arms, legs, hands, or feeth. Swollen or painful joint(s)i. Knee trouble ( , locking, giving out, pain or ligament injury, etc.)b. COMPONENTC oastGuardMark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 1 of 3 Pages Adobe Professional XIThe public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

7 Send comments regarding the burden estimate or burden reduction suggestions to the Department ofDefense, Washington Headquarters Services, at Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE DoD ID NO. (If applicable)c. EMAIL ADDRESS PRIVACY ACT STATEMENTAUTHORITY: 10 136, Under Secretary Of Defense For Personnel And Readiness; DoD Directive , United States Military Entrance Processing Command; DoD Instruction , Medical Standards for Appointment, Enlistment, or Induction in the Military Services; and 9397 (SSN), as PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Forces.

8 The information collected on this form is used to assist DoD physicians inmaking determinations as to acceptability of applicants for military service and verifies disqualifying Medical condition(s) noted on the prescreening form (DD 2807-2). An additional collection ofinformation using this form occurs when a Medical Evaluation Board is convened to determine the Medical fitness of a current member and if separation is USE(S): The Routine Uses are listed in the applicable system of records notice found at: : Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces.

9 An applicant'sSSN is used during the recruitment process to keep all records together and when requesting civilian Medical records. For an Armed Forces member, failure to provide the information may result in theindividual being placed in a non-deployable status. The SSN of an Armed Forces member is to ensure the collected information is filed in the proper individual's Sensitivity to chemicals, dust, sunlight, Inability to perform certain motionsc. Inability to stand, sit, kneel, lie down, Other Medical reasons (If yes, give reasons.) you been refused employment or been unable to hold a job or stay in school because you ever been denied life insurance?

10 22. Have you ever had, or have you been advised to have any operations or surgery? (If yes, describe and give age at which occurred.) you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)20. Have you ever been treated in an Emergency Room? (If yes, for what?) you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.)